Physician Orders Document Management and Guidelines

Physician’s orders are essential to give clinicians the road map they need to get home-care patients through from admission to discharge. They are the heart of the Medicare Plan of Care and should be specific, detailed, and include Medicare-covered services. When changes are necessary, they are generally secured through writing verbal orders based on a phone conversation with the patient’s physician. Note that verbal orders must also meet Medicare requirements. In order for physician’s orders to become defensible medical records, special care must be taken in storage.

The Many Inherent Complications in Storing Physician’s Orders Documents

When it comes to physician’s orders document management, nothing is as important as organization. Not only do physicians needs instant access to active files, but they need to be able to find and review older files as well. In today’s world of large storage facilities, it’s easy for these files to get lost or take hours to find.

But this isn’t the only issue with the organization of these and other medical files, including:

Organization is essential, but HIPAA compliance is crucial. Some states have their own, more stringent rules and regulations for storing medical files. Physicians should consider the federal and state regulations that affect their business and then follow whichever laws are the most stringent to ensure they’re in compliance with them all.

Physicians with small practices simply don’t have the room to keep paper files on every patient. When they’re first building their practice it may be possible to have a few file cabinets, but as time goes on, and each physician must keep the records of everyone they’ve seen for years after their last visit—even if they only saw them once—what used to fit into a few filing cabinets is now piling up on the floor.

Physicians in larger group practices or hospitals also don’t have room in-house to store all of their relevant medical files. The solution for them is often to utilize offsite storage facilities, which have their own inconveniences, such as these listed below:

Physicians can’t instantly access older files. Instead, they must call the facility and have the file pulled, or send someone from their own office to go pull the file. This wastes not just time and resources, but in some cases the information in the file may be necessary for the physician to provide the best medical care. While they’re waiting for the file, they may make mistakes or missteps they wouldn’t have made if they’d had all the relevant medical information.

Security can be a serious concern. Though these storage facilities may have taken steps to prevent theft, the reality is that individual physicians can’t be sure that their files are completely secure.

In the event of fire, flood, or other natural, devastating events, all files could be wiped out in a single day. This could be catastrophic for a medical practice.

Since files aren’t onsite, many offices end up creating duplicate files to keep at the facility. They won’t have all of the information in the file but will have the basics such as name, address, allergies, and a brief history of care. Once again, this wastes time, and it increases the chance for mistakes on their medical record. The number one cause of errors is human error—and the chances of a human error increase every time a new file is created.

There Is an Alternative Way to Create Defensible Medical Records

While trying to maintain records can seem difficult, the reality is that there is a better way: document management software (DMS). It allows physicians to move away from physical files and store their documents electronically.

There are as many advantages to these options as there are disadvantages to keeping paper files:

Significantly reduced overhead. There is of course a cost associated with implementing and using DMS, but it can easily pay for itself when physicians consider the money they’ll no longer spend on filing cabinets, paper, toner, fax machines, copiers, postage, and the capital involved in paying employees to file papers and retrieve them when needed.

Better security. The major DMS options feature the cutting-edge in electronic security, including advanced encryption.

Frequent back-ups to offsite data centers. The biggest concern of many physicians is what will happen if the electronic documents are damaged. First of all, this is less likely than physical files being damaged. Secondly, the major players in the DMS world all frequently backup their data to off-site data centers to ensure stored data is secure.

Your Top Choice in the DMS Field

There are numerous players in the DMS field but eFileCabinet offers superior services in a number of ways. As soon as you use the software it will be clear that the organizational structure is simply superior to other DMS options on the market. Enjoy the peace of mind of enhanced security, including 256-bit encryption and role-based securities that make it simple to allow approved users to access the confidential documents they need, while also protecting files from those who don’t have approval.

eFileCabinet offers built in compliance with HIPAA and third-party software integration that allows you to use it with your current software programs like Microsoft Office Suite and QuickBooks. There’s no question that electronic media is easier to access, use, and keep safe compared to physical files. When you’re ready for a 15-minute demo that will prove the many advantages of eFileCabinet, simply fill out the form on this page.